Healthcare Provider Details

I. General information

NPI: 1073827093
Provider Name (Legal Business Name): PEPPERMINT DENTAL-SAN MATEO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2010
Last Update Date: 08/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

333 SAN MATEO BLVD SE UNIT A
ALBUQUERQUE NM
87108-2919
US

IV. Provider business mailing address

7301 STATE HIGHWAY 161 STE 198
IRVING TX
75039-2880
US

V. Phone/Fax

Practice location:
  • Phone: 505-268-8888
  • Fax:
Mailing address:
  • Phone: 972-869-3789
  • Fax: 972-869-3791

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number
License Number State

VIII. Authorized Official

Name: MARY PU
Title or Position: CFO
Credential:
Phone: 972-869-3789